1. Telehealth Medical Home Model: Strategies and Successes Presented by: Bonnie Britton, MSN, RN Telehealth Clinical Network Director/Development Dir. Eastern Montana Telemedicine Network Retreat August 31, 2009

2. Roanoke Chowan Community Health Center RCCHC’s Mission: Improve health status of underserved and indigent individuals in northeastern North Carolina by: Enhancing access to quality health care Implementing coordinated health care delivery best practices Located in rural North Carolina 17 PCP at 3 clinics serving over 14,500 patients Population: 21% uninsured 41% high school completion 70% African American

3. Health Disparities Cardiovascular Disease Diabetes Mellitus Hypertension Barriers to care Transportation Economic Status Low literacy Roanoke Chowan Community Health Center

4. Medical Home Model Prevention Primary Care Chronic Care Management Patient Education Coordination of Care Community Outreach Longitudinal Care

5. Patient Provider Telehealth Network Driven by PCP Individualized to patient Daily remote monitoring Daily RN chronic care management PCP responds to critical indicators allowing early detection and intervention Follow-up with patient by PCP

6. Patient Provider Telehealth Network NC HWTF Health Disparities Phase I Goals Reduce health disparities Increase access to care Overcome barriers to care Contain health care expenditures Create community based telehealth network

7. In-home daily remote monitoring Objective monitoring (BP, Pulse, Blood Sugar, O2 saturation, Weight) Subjective monitoring (signs/symptoms) Daily Chronic Care Management Medication compliance assessment Nursing health assessment Education PCP intervention and patient follow-up as needed PPTN Phase I Target Populations CVD, DM, HTN

8. In-home monitoring 198 CVD/DM/HTN patients Kiosks screenings 43 population based CVD/DM/HTN screenings for 2,507 citizens PPTN Phase I Populations Served

9. Enhanced self-management skills Increased self care Empowered patient/caregiver Improved patient health status Decreased HgA1c Decreased FSBS Decreased BP Decreased weight In-home Patient Outcomes

10. Patient Impact Increased access to medical care Reduced health disparities Increased satisfaction Increased compliance to medical regimen In-home Patient Outcomes

11. Total Number of Hospitalizations Prior Telehealth: $1,693,698 (316 Bed Days) During Telehealth: $626,387 (154 Bed Days) Post Telehealth: $503,953 (157 Bed Days) n = 64 In-home patients Telehealth patient hospitalizations decreased 39% from 6 months prior to telehealth to during telehealth. Patient hospitalizations decreased 48% from prior to telehealth to post telehealth. RCCHC / PPCTN Patient Charge Data Ending March 2008 Analyzed charges are related to diseases being monitored.

12. Total Number of Emergency Department Visits Before Telehealth: $83,580 During Telehealth: $58,159 After Telehealth: $35,590 n = 52 In-home patients Telehealth patient ED visits decreased 43% from 6 months prior to telehealth to during telehealth. Patient ED visits decreased 53% from prior to telehealth to post telehealth. RCCHC / PPCTN Patient Charge Data Ending March 2008 Analyzed charges are related to diseases being monitored.

13. Total Number of Hospitalizations Prior to Telehealth: 66 (316 days total) and 30 ED visits During Telehealth: 41 (154 days total) and 17 ED visits Post Telehealth: 33 (157 days total) and 21 ED visits Telehealth patient charges decreased 61% from 6 months prior to telehealth to during telehealth. Patient charges decreased 70% from prior to telehealth to post telehealth. n = 64 In-home patients RCCHC / PPCTN Patient Charge Data Ending March 2008 Analyzed charges are related to diseases being monitored.

14. Strategies for Expansion Vertical Networks Centers of Aging: kiosk monitoring Senior Centers: kiosk monitoring PACE Programs: in-home monitoring Hospital discharge monitoring: in-home monitoring Diagnosis based: in-home monitoring CHF DM

15. Strategies for Expansion Horizontal Networks Expansion to CHCs CHC funded Grant funded Replication to 6 additional CHCs Expansion to other PCP practices

16. RCCHC CVD Pts Roanoke Chowan Community Health Center Existing Patient Provider Telehealth Network June 30, 2009 RCCHC HTN Pts RCCHC DM Pts Gates Co. Medical Center DM & CVD Pts ECU Cardiology- RCCHC In Home Monitoring HF Pts Roanoke Chowan Hospital Patient Provider Telehealth Network RCH Hospitalized DM Pts Post Discharge Piedmont Health Systems CVD Pts Piedmont Senior Care CVD Pts Rural Health Group DM Pts Senior Centers DM & CVD Pts

17. Goal 1: Reduce rate of CVD and it’s complications Objectives: Replicate current PPTN Provide daily in-home monitoring for 6 months 50% compliance to remote monitoring 10% reduction in LDL and BP Goal 2: Obtain NC Medicaid Reimbursement Objectives: Decrease ER visits and hospitalizations 30% Reduce NC Medicaid expenditures NC HWTF Phase II PPTN Goals and Objectives

18. Horizontal CHC Telehealth Network July 1 2009 – June 30 2012 Greene County CHC PCPs/CVD patients Tri-County CHC PCPs/CVD patients Rural Health Group PCPs/CVD patients Kinston CHC PCPs/CVD patients RCCHC Telehealth RN and Team Cabarrus CHC PCPs/CVD patients RCCHC PCPs/CVD patients

19. NC Medicaid CVD and/or Heart Failure NYSC III/IV and require frequent monitoring, health assessment and education. Frequent exacerbations Frequent use of health care system Willing to carry out mutually agreed responsibilities Desire to participate in the program Have basic cognitive skills Able to learn to use monitors Phase II PPTN Target Patient Population

20. In-home remote monitoring equipment 1.0 FTE RN to provide daily monitoring and chronic care management 0.03 FTE Data Analyst for data collection and evaluation Customized policies and procedures and implementation documents Webinar and on-site implementation and planning meetings Equipment training On-site initial equipment deployment On-site quarterly meeting PPTN Phase II RCCHC Staff Deliverables

21. One designated nurse champion Identifies CVD/HF patients Completes Plans of Care Completes patient consent forms Installs and de-installs telehealth equipment Troubleshoots and maintains equipment List of appointed program staff and contact information EMR access for RCCHC RN Quarterly data reports (height, LDL) Provides oversight care of CVD/HF patients PPTN Phase II CHC Staff Deliverables

22. IRB approved Contract with PhD Wake Forest University Clinical dataFinancial data DemographicsHospitalizations/costs WeightER visits/costs Blood PressurePCP visits/costs Pulse LDL Medication Classifications Evaluation

23. Bonnie Britton 252-209-0237 bbritton@pcmh.com www.rcchc.org Contact Information